Curriculum · Gynecology / Women's Health / Infertility / Perinatal Care / Birth Spacing
Postpartum contraception
What it is
Any postpartum women should have contraception after day 21. From there the timing of each method is set by whether the woman is breastfeeding, and the methods divide into progesterone only, combined hormonal, IUD and natural.
Day 21 is where the count starts because the earliest date of ovulation in a non-breastfeeding woman is thought to be day 28 postpartum, and sperm can survive for up to 7 days. A woman who is exclusively breastfeeding will take longer to ovulate, but contraception should still be advised if pregnancy is not desired. Emergency contraception is also not required before day 21 postpartum.
How it is treated
Progesterone only pills can be started at any time postpartum, but if they are started after day 21 an additional contraception method should be used for 2 days. They are one tablet a day, taken at the same time each day, and are indicated in breastfeeding but 6 wks postpartum, in a patient who can't take COCP, and from the 1st day after abortion. Injectable DMPA (Depo Medroxyprogesterone Acetate, Depo-Provera) is 150mg IM 3 monthly, the injection taken within 5 days of the cycle, with a back up method for 7 days if it is not given in the first 5 days of the period; it too is indicated in breastfeeding but 6 wks postpartum, and also in epilepsy, sickle cell, the obese patient and the patient on anticoagulant. The progesterone implant contains etonogestrel 68mg, is inserted subdermal on day 1-5 of the cycle with a back up method for 4 days otherwise, is effective for 3 years, and is called the most effective method. Combined hormonal contraception is contraindicated in the 1st 6 months in lactating women; it is given as the combined oral contraceptive pill, as one patch every week, or as a vaginal ring placed for 3 weeks with 1 week ring free. IUDs are inserted after 4 weeks in non-breastfeeding women and after 6 weeks in breastfeeding women in one source, while another states that the Mirena intrauterine system and copper IUD can be used from 4 weeks postpartum with no separate wait for the breastfeeding woman, so the two do not agree for her; of the two IUDs, one is effective up to 10 years and reduces the risk of cervical and endometrial cancers, while the other is effective up to 5 yrs, suits women with heavy and painful period, and reduces the risk of PID and cervical cancer. Lactational amenorrhea needs exclusive breastfeed and a baby under 6 months, and it shouldn't be used in a patient with HIV.
The FSRH advice for each method fills in the postpartum timing. The progestogen only pill can be started at any time postpartum in both breastfeeding and non-breastfeeding women, and only a small amount of progestogen enters breast milk, which is not harmful to the infant. The combined pill may be started from day 21, and this will provide immediate contraception; started after day 21 it needs additional contraception for the first 7 days, and it may reduce breast milk production in lactating mothers. The progestogen only implant can be inserted at any time, although contraception is not required before day 21. The copper IUD should not be inserted before day 28 postpartum, because of the increased risk of uterine perforation if it is inserted before this time. Lactational amenorrhoea is 98% effective providing the woman is fully breast-feeding with no supplementary feeds, is amenorrhoeic, and is less than 6 months post-partum. After day 21, progesterone only emergency contraception, Levonelle and ellaOne, can be used in both breastfeeding and non-breastfeeding women. A woman on enzyme-inducing drugs should be advised to switch to a method unaffected by them, or to use additional contraception until 28 days after stopping the treatment.